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Evaluation of Inpatient Clinical Documentation Readiness for ICD-10-CM

Author: DeAlmeida, Dilhari R; Watzlaf, Valerie J.M.; Anania-Firouzan, Patti; Salguero, Otto; Rubinstein, Elaine; Abdelhak, Mervat N.; Parmanto, Bambang

Source: Perspectives in Health Information Management

Publication Date: January 2014


Abstract


This research study examined the gaps in documentation that occur when coding in ICD-10-CM. More than 4,000 diagnoses from all chapters were coded from 656 electronic documents obtained from a large integrated healthcare facility at the time the study was conducted (2012)....